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PATIENT SAFETY

A Novel Process for Introducing a New Intraoperative Program: A Multidisciplinary Paradigm for Mitigating Hazards and Improving Patient Safety

Jose M. Rodriguez-Paz, MD^*, Lynette J. Mark, MD^*, Kurt R. Herzer^*, James D. Michelson, MD, Kelly L. Grogan, MD^*, Joseph Herman, MD, MSc, David Hunt, RN, Linda Wardlow, RN, Elwood P. Armour, PhD, and Peter J. Pronovost, MD, PhD^*

From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont; Departments of Radiation Oncology and Molecular Radiation Sciences, and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence and reprint requests to Jose M. Rodriguez-Paz, MD, Department of Anesthesiology and Critical Care Medicine, 600 North Wolfe St., Meyer 297 A, Baltimore, MD 21287. Address e-mail to jrodrig1{at}jhmi.edu.

Abstract

BACKGROUND: Since the Institute of Medicine’s report, To Err is Human, was published, numerous interventions have been designed and implemented to correct the defects that lead to medical errors and adverse events; however, most efforts were largely reactive. Safety, communication, team performance, and efficiency are areas of care that attract a great deal of attention, especially regarding the introduction of new technologies, techniques, and procedures. We describe a multidisciplinary process that was implemented at our hospital to identify and mitigate hazards before the introduction of a new technique: high-dose-rate intraoperative radiation therapy, (HDR-IORT).

METHODS: A multidisciplinary team of surgeons, anesthesiologists, radiation oncologists, physicists, nurses, hospital risk managers, and equipment specialists used a structured process that included in situ clinical simulation to uncover concerns among care providers and to prospectively identify and mitigate defects for patients who would undergo surgery using the HDR-IORT technique.

RESULTS: We identified and corrected 20 defects in the simulated patient care process before application to actual patients. Subsequently, eight patients underwent surgery using the HDR-IORT technique with no recurrence of simulation-identified or unanticipated defects.

CONCLUSION: Multiple benefits were derived from the use of this systematic process to introduce the HDR-IORT technique; namely, the safety and efficiency of care for this select patient population was optimized, and this process mitigated harmful or adverse events before the inclusion of actual patients. Further work is needed, but the process outlined in this paper can be universally applied to the introduction of any new technologies, treatments, or procedures.